Edited by Daniel Cuttica, DO
The calf muscle is made up of two muscles: the gastrocnemius and soleus. The gastrocnemius is larger and more superficial. Both of these muscles combine to form the Achilles tendon.
When the calf muscle is too tight, there may be difficulty bending the foot backward, This tightness is called a gastrocnemius equinus contracture. It is named after the “ankle” position of horses (equine), which point downwards. An equinus contracture can cause altered walking and lead to various foot and ankle problems over time.
A gastrocnemius recession is a procedure that lengthens the gastrocnemius muscle and is often utilized to treat conditions caused by a tight calf muscle. It is indicated for patients who have tightness in their outer calf muscle (the gastrocnemius), and who have failed non-operative management, including several months of Achilles stretching exercises.
A gastrocnemius equinus contracture is characterized by the inability to bend the ankle joint past a neutral position (right angle to the lower leg) with the knee straight (Figure 1). Rather than “walk on their toes”, most people naturally and unconsciously “compensate” for an equinus contracture by having more motion through the joint in front of the ankle joint (the transverse tarsal joint – see Figure 2). Many gastrocnemius equinus contractures are subtle and patients are often asymptomatic. However, this midfoot compensation often leads to increased repetitive load to various structures in the foot during standing and walking. Therefore, the presence of an equinus contracture may predispose to the development of certain foot conditions, such as plantar fasciitis, acquired adult flatfoot deformity, metatarsalgia, or Achilles tendon disorders. Often a regular calf stretching program (with the knee straight) can lead to succesful non-operative management of symptoms. However, in some instances surgical treatment (often combined with other procedures) is indicated. Gastrocnemius contractures are believed to develop either from:
- A hereditary predisposition (our evolutionary ancestors had equinus contractures)
- Aging, which tends to cause muscles to stiffen
- Medical conditions such as diabetes, which cause muscle to stiffen
- Immobilization following ankle or foot trauma – particularly if the ankle is splinted in an equinus (downward) position
- Nerve injury, which can cause an imbalance of muscles in the leg causing the gastrocnemius muscle to tightenrve injury, which can cause an imbalance of muscles in the leg causing the gastrocnemius muscle to tighten
Figure 1: Foot does NOT reach a right angle to the lower leg with the knee straight
Figure 2: Ankle motion PAST neutral with compensation through joint in front of ankle
Although there are various ways of performing a gastrocnemius recession, they all involve performing an adequate release of the gastrocnemius tendon, in order to lengthen the calf muscle. Typically an incision is made on the back inside part of the lower leg (Figure 3), and the gastrocnemius tendon is exposed. Once the tendon is exposed, it is cut and either left to heal on its own or sutured to the underlying tissue in the newly lengthened position. This effectively lengthens the calf muscle. Patients will now have the same ankle motion with their knee straight that they previously had with their knee bent. After the calf muscle is lengthened, the wound is closed up. The leg is placed in a splint or cast to hold the foot and ankle in a neutral position.
Figure 3: Typical location of calf incision (dotted line)
For the first 2-6 weeks, the patient is in a CAM boot, walking boot, or equivalent. It is important that the foot is maintained at a right angle to the lower leg with casting, bracing, or splinting for the first two weeks. Initially, there is a moderate amount of pain in the calf (feels like a smack), but this will settle down in the first couple of weeks. Calf stretching exercises can begin when the patient is comfortable. Also, after the pain has settled in the calf, it’s important to strengthen the calf since the patient will lose strength in the short term. By the 6-8 week mark, the patient can usually walk reasonably normally; however, it my take 8-12 months to regain 90-95% of the original calf strength.
A gastrocnemius recession is often done in conjunction with other procedures, thus slower surgical recoveries (ex. bone cuts that need to heal) will take precedence.
- Scarring: A prominent scar where the incision was made may develop in some patients.
- Tethering of the skin: The skin incision may become adherent to the tissue overlying the calf muscle (fascia). This can cause tethering of the skin when the calf muscle moves. Often deep massage to this area early in the post-operative period can break up these adhesions.
- Injury/Irritaion to the sural nerve: The sural nerve runs along the gastrocnemius. Although uncommon, this nerve can become irritated or even injured as a result of the surgery. Injury or irritation may lead to pain and/or numbness around the outside of the foot.
- Calf weakness: Some initial calf weakness occurs in all patients. However, it is usually not clinically significant and typically resolves within 9-12 months of surgery. However, 5-10% of patients may have noticeable calf weakness and atrophy that persists longer than expected.
Edited on August 14, 2015